Mood Disorders Workshop 2010 Dr Andrew Howie / Dr Tony Fernando Psychological Medicine Faculty of Medical and Health Sciences University of Auckland Goals To learn about the clinical presentation of mood disorders Signs and symptoms Mental status reporting How to ask questions To be able to differentiate the various types of pathological mood states Outline of treatment To understand how it is to have a mood disorder from a person who experiences it Not included in today’s workshop but student has to know… Etiology and Pathophysiology Genetics Social/ Developmental and Environmental factors Details of variant forms Neurobiology Abnormalities in neurotransmission Neuroimaging Neuroendocrine functioning Useful resources (for further reading) American Psychiatric Association guidelines: http://www.psych.org/MainMenu/PsychiatricPrac tice/PracticeGuidelines_1.aspx NICE Guidelines: http://www.nice.org.uk/ RANZCP Guidelines: http://www.ranzcp.org/resources/clinical- memoranda.html Concept of Mood Spectrum Euphoric Ecstatic Optimistic, cheerful “Glass half full” Even mood, stable, content Pessimistic “Glass half empty” Hopeless, worthless suicidal Individualized Set point/ range Reactivity to situations/ thoughts Neutral Positive Negative Despite fluctuations, the individual still is able to function socially, vocationally Modifiable? Pathologic equivalents Euphoric Manic Ecstatic Hypomanic Optimistic, cheerful Hyperthymic “Glass half full” Euthymia ( not pathologic) Even mood, stable, content Pessimistic Dysthymic “Glass half empty” Depressed Hopeless, worthless suicidal Pathologic Changes Resetting of “set point” Sustained, unshifting mood state Change in reactivity to situations/ thoughts Impaired functionality- socially, work Change in sense of self Mood Disorders Depressive Disorders Bipolar Disorders Predominant mood is Has elevations/ mania depression, no and depressions elevations/ mania Bipolar disorder, manic Major Depression, Bipolar disorder, single episode depressed Major Depression, Bipolar disorder, mixed recurrent Cyclothymic disorder Dysthymic Disorder Bipolar disorder, not Depressive Disorder, otherwise specified not otherwise specified Specific Mood Disorders Depressive Disorders Major Depression, single episode Major Depression, recurrent Dysthymic Disorder Depressive Disorder, not otherwise specified Other Variants: Atypical depression, Postpartum depression, Seasonal Affective Disorder, Depression with psychosis Depressive Disorders Must exclude: Mixed Episode Secondary to General Medical Condition Secondary to Substance Abuse Bereavement- Duration and Severity Specific Mood Disorders Bipolar Disorders Bipolar disorder, manic Bipolar disorder, depressed Bipolar disorder, mixed Cyclothymic disorder Bipolar disorder, not otherwise specified Other Variants: Bipolar I and II, rapid cycling, ultra rapid cycling Major Depressive Disorder DSM IV 5 or more of the following • with at least one being depressed mood or anhedonia • for at least two weeks and • with change in function 1. Depressed mood 2. Loss of interest / pleasure or Anhedonia 3. Weight loss change 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feelings of worthlessness /guilt 8. Decreased ability to think /concentrate 9. Suicidality or thoughts of death Major Depressive Disorder Mnemonic Depressed Mood S Sleep disturbance* ↕ I Interest ↓ G Guilt levels  E Energy* ↓ C Concentration* ↓ A Appetite* ↕ P Psychomotor disturbances S Suicidal thoughts * neurovegetative symptoms- sleep, energy, concentration, appetite, libido Dysthymia/ Dysthymic Disorder DSM IV Depressed mood for most of the day more days than not at least 2yrs ( children and adolescents 1yr) Chronic, low grade depression 2 or more ( not 5) 1. Poor appetite or overeating 2. Insomnia or hypersomnia 3. Low energy or fatigue 4. Low self esteem 5. Poor concentration / difficulties making decisions 6. Feelings of hopelessness Never without symptoms for more than two months No MDE for first two years (one year) of the disturbance Dysthymia Mnemonic A – Appetite changes C – Concentration difficulties H – Hopelessness E - (Self) esteem low W – Worthlessness S – Sleep disturbances. Dysthymia rule of 2’s At least 2 symptoms Minimum 2 years Never without symptoms for more than 2 months Other Depressive symptoms not in the 9* Irritability and anger Unexplained physical complaints (somatizers) In some severe depressions, can have delusions and hallucinations * 9 DSM IV symptoms DSIGECAPS Interview of patient with depression observe interview process, how to ask questions document Mental Status Examination (use template) MSE in Depression (Some possible findings) Appearance, attitude, activity: Sometimes dishevelled, markers of self harm/suicide attempts, may be very cooperative or apathetic, psychomotor agitated or retarded. Speech: latent, slow, soft, loss of prosody (or the opposite if agitated and upset). Affect: dysphoric, loss of mobility, intensity varies, range often restricted, reactivity may be diminished, congruent with content of thought (possibly not, if psychotic). Mood: dysphoric, dysthymic, anxious. MSE in Depression (Continued) Thought: stream slowed, form – loss of goal through inattention, distractibility. Content: nihilistic themes, loss, guilt/ helplessness/hopelessness/ worthlessness. Nihilistic delusions (if psychotic). Perception: Hallucinations if psychotic. Memory and cognition: Decreased attention and concentration (and consequent deficits in other modalities). Pseudodementia. Insight: Usually intact (but beware masked depressin e.g. alexithymia). Judgment : often impaired e.g self harm, not seeking therapy. Post Interview Discussion of Interview Discussion of MSE Bipolar Disorder 2 poles Depression Similar to Major Depression but not quite Mania Bipolar Disorder DSM IV Manic episode ( seen in Bipolar I) A. A distinct pattern of abnormally and persistently elevated mood at least one week or any duration if hospitalized B. Three or Four present to a significant degree 1. Inflated self esteem or grandiosity 2. Decreased need for sleep 3. More talkative than usual 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility 6. Increase in goal directed activity or psychomotor agitation 7. Excessive involvement in pleasurable activity that have high risk of painful consequences Mania Mnemonic D – Distractibility I – Increased goal-directed energy G – Grandiosity F – Fast thinking A – Activities (pleasurable with painful consequences) S – Sleeplessness T – Talkative Or diagram Bipolar Disorder Mania MYTH: always cheerful, enthusiastic, happy, euphoric irritable, hostile, cutting Inflated self esteem/ grandiosity Neurovegetative symptoms A brain going on hyperdrive can become psychotic Increased energy, not requiring sleep Brain processing info faster than usual Less need for food Bipolar Disorder DSM IV Exclusions Not due to general medical condition, substance abuse Not a Mixed episode Mania caused by treatment for depression should not count towards a diagnosis of bipolar 1 Bipolar Disorder DSM IV Hypomania ( less severe than mania) Criteria are as for mania but: “The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization and there are no psychotic features” Seen in Bipolar II ( depressions and hypomania) Bipolar Disorder Depressed phase Longest, more frequent, undiagnosed, generally untreated phase Apart from usual depressive symptoms found in MDE, can have: Anxiety ( non specific) Hypersomnia Psychomotor retardation Poor response to antidepressants or can switch to mania Risk issues that need to be assessed Depression Suicide Poor self cares Unable to care for dependents Suicide- Homicide ( ie postpartum) Mania Rarely suicide Impulsivity- anger, lashing out Less inhibitions: driving; sexual; spending Because of loud/ “in your face” behaviour, can be assaulted Co-morbidities of Mood disorders Anxiety disorders Substance Abuse and Dependence / Pathological Gambling Significant Social Stress / Family Dysfunction Interview of manic patient observe interview process, how to ask questions document Mental Status Examination (use template) MSE in Mania (Possible findings) A / A / A: Dishevelled, dismissive, energetic, agitated (pitfall – can hold things together for interview of brief duration). Speech diminished latency, rapid, pressured (difficult to interrupt), loud, increased prosody. Affect: elated / euphoric, irritable, very mobile, intense, range may be restricted or increased, reactivity may be increased, may be incongruent. Mood: elevated or irritable MSE in Mania (Continued) Stream of thought: increased Form of thought: tangential, circumstantial, flight of ideas, loosening of associations (e.g. clang associations). Content of thought: grandiose, persecutory themes sometimes. Memory and cognition: may be inattentive and distractible, with associated impairment of other findings. Insight: Diminished Judgment: sometimes severely impaired. Post interview Discussion of Interview Discussion of MSE Some helpful interview questions Asking about mood Asking about anhedonia Asking about thoughts of suicide Asking about hallucinations Asking about mania Asking about comorbidities (anxiety / trauma / substance abuse and dependence) See Mark Zimmerman’s Interview Guide for Evaluating DSM IV Psychiatric Disorders and the MSE- available at Philson Management Safety / Status (Mental Health Act) / Situation Further information – Collateral / Observation / Investigations / Lab Therapeutic Alliance / Engagement Psychoeducation – Family focussed therapy Specific Treatment Goals – Bio / Psycho / Social / Cultural / Spiritual Relapse Prevention Rehabilitation Goals Reference for management plan http://www.psychiatryonline.com/pracGuide/loa dPracQuickRefPdf.aspx?file=Bipolar_QRG Accessed 28 January 2010 .